Dear Dr. VAUTHIER,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 02 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Afagh Hassanzadeh Rad

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

“This research received no specific grant from any funding agency in the public, commercial, or not for-profit sectors.”

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. 

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

“The author(s) received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. We note that your Data Availability Statement is currently as follows: “All relevant data are within the manuscript and its Supporting Information files. Interview transcripts are available from the corresponding author upon reasonable request, in accordance with ethical guidelines and participant consent. The study was approved by the South-East VI Research Ethics Committee (Reference: 24.00907.000253).”

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

4. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found.

5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

6. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

7. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: This qualitative study explores the lived experiences of individuals with Type 1 Diabetes (T1D) who participate in ultra-endurance sports, using a constructivist grounded theory approach. Based on 13 in-depth interviews, the authors identify four main themes: identity reconstruction, self-management, resilience, and social visibility. The paper provides meaningful insights into how living with a chronic condition can be transformed from a perceived limitation into a source of personal empowerment. The topic is original and highly relevant, addressing the intersection of chronic illness, identity, and extreme physical performance — an area that has received limited scholarly attention. The study is theoretically sound and methodologically coherent; however, several aspects could be improved to enhance clarity and rigor. Title: Please revise the manuscript title to remove the redundant word “Title.” Language and Style: A minor English language and style edit is recommended to improve overall fluency and readability. Sample Composition: The sample (n = 13) is relatively small and predominantly male (11 men, 2 women), which limits the transferability of findings. The authors should discuss the gender imbalance and its possible influence on the interpretations. Researcher Positionality and Bias: The primary author’s dual role as both a healthcare professional and a person living with Type 1 Diabetes warrants deeper reflexivity. Please elaborate on how this insider position may have shaped data collection and interpretation. There is a potential risk of bias related to the dual role of the main researcher, who is both a healthcare professional and a person living with Type 1 Diabetes. Comparative Context: The lack of comparison with other populations—such as non-athletes, individuals with varying physical activity levels, or those facing more complex sociomedical conditions—limits the interpretative scope of the study. Future comparative or longitudinal designs could provide deeper insight into the diversity of adaptation trajectories. Overall, this is an insightful and well-conducted qualitative study that contributes valuable perspectives to the literature on chronic illness and identity reconstruction. Addressing the above points would further strengthen the manuscript’s analytical depth and methodological transparency

Thank you again for the opportunity to review this work.

Sincerely

dr. matin mojaveri samak

Reviewer #2: Provide a dedicated table (e.g., Table 1: Participant Characteristics) with pseudonymized data: age, gender, years since T1D diagnosis, age at diagnosis, type/frequency of ultra-endurance events completed (e.g., UTMB, Diagonale des Fous, Ironman, 6-day races), glycemic control indicators if shared (e.g., recent HbA1c range, use of CGM/hybrid closed-loop/pump), and any notable complications or technology use.

Other relevant: Kellett & Winston (2021) on T1D runners' "supercrip" narratives; Thomas & Röhsli (2018) on adventure racing; or broader chronic illness/extreme sport studies (e.g., spinal cord injury ultrarunners).

Acknowledge potential positive bias .

Add clinical implications: How should endocrinologists respond when patients express ultra-endurance goals?

Consider slight refinement of title for precision: "Chronic Illness and Extreme Performance: How Ultra-Endurance Transforms

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: Yes:  matin mojaveri samak

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures 

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. 

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Chronic Illness and Extreme Performance: Type 1 Diabetes in Ultra-Endurance

PONE-D-25-52862R1

Dear Dr. VAUTHIER,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Afagh Hassanzadeh Rad

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: